Understanding Skin Failure: A Scoping Review

Abstract

OBJECTIVE To map the use of the term “skin failure” in the literature over time and enhance understanding of this term as it is used in clinical practice. DATA SOURCES The databases searched for published literature included PubMed, Embase, the Cumulative Index for Nursing and Allied Health Literature, and Google Scholar. The search for unpublished literature encompassed two databases, Open Gray and ProQuest Dissertation and Theses. STUDY SELECTION Search terms included “skin failure,” “acute skin failure,” “chronic skin failure,” and “end stage skin.” All qualitative and quantitative research designs, editorial, opinion pieces, and case studies were included, as well as relevant gray literature. DATA EXTRACTION Data collected included author, title, year of publication, journal name, whether the term “skin failure” was mentioned in the publication and/or in conjunction with other skin injury, study design, study setting, study population, sample size, main focus of the publication, what causes skin failure, skin failure definition, primary study aim, and primary outcome. DATA SYNTHESIS Two main themes of skin failure were identified through this scoping review: the etiology of skin failure and the interchangeable use of definitions. CONCLUSIONS Use of the term “skin failure” has increased significantly over the past 30 years. However, there remains a significant lack of empirical evidence related to skin failure across all healthcare settings. The lack of quality research has resulted in multiple lines of thinking on the cause of skin failure, as well as divergent definitions of the concept. These results illustrate substantial gaps in the current literature and an urgent need to develop a globally agreed-upon definition of skin failure, as well as a better understanding of skin failure etiology.

The Past, Present, and Future of Skin Failure

“…13 A recent scoping review was done to map the use of the term skin failure in hopes of enhancing understanding of how it is used in clinical practice. 24 The authors identified 180 articles that met the inclusion criteria focused on identifying and synthesizing literature on unavoidable skin injuries appearing at end of life. Four themes were identified: (1) four names for the same problem, namely, skin failure, SCALE, KTU, and Trombley-Brennan; (2) knowledge gaps exist on the pathophysiology of the KTU as it currently is based on hypotheses; (3) differences exist between the KTU and the other injuries; and (4) gaps also exist in care approaches.…”

“…Four themes were identified: (1) four names for the same problem, namely, skin failure, SCALE, KTU, and Trombley-Brennan; (2) knowledge gaps exist on the pathophysiology of the KTU as it currently is based on hypotheses; (3) differences exist between the KTU and the other injuries; and (4) gaps also exist in care approaches. 24 Another scoping review conducted in 2019 identified that knowledge on the KTU is limited, no validated assessment tool is available, and the KTU may be misclassified as a PI. 25 One assessment scale was reported in the literature based on a retrospective study of 52 acute care patients who experienced ASF prior to death.…”

Cutaneous Anomalies of the Critically Ill Patient

“…11 This condition has several names, including Kennedy terminal ulcers, skin changes at life's end, and Trombly-Brennan terminal tissue injuries. 12 Furthermore, reports in the literature suggest skin failure may occur on a spectrum that includes acute, chronic, and end-of-life skin. 11 Acute skin failure appears during a critical illness such as shock.…”

“…Initial stages of skin failure may present as mottling, blisters, ulceration, and even gangrene. 12 Skin failure should be considered if skin damage appears suddenly and rapidly deteriorates to necrosis or full-thickness tissue loss. 13 Patients with skin failure may be misdiagnosed as having a deep tissue injury, or unstageable or full-thickness pressure ulcer or injury.…”

Skin failure: A two-faced concept

“…Some attempts have been made to define "skin failure" with two distinct and quite different meanings, which reflect, in a way, an "inside out" vs an "outside in" pathogenetic process. [1][2][3][4][5] On one hand, the term has been used, mainly in the "wound care" area, to refer to regional or localized loss of substance, such as pressure ulcers, especially in critically ill patients. [6][7][8][9][10] Skin failure, in this meaning, is defined as "an event in which the skin and underlying tissue die due to hypo-perfusion that occurs in concomitance with failure of other organs," especially in the context of a Multi-Organ Dysfunction Syndrome (MODS), or as part of the dying process at the end of life (Skin Changes at Life's End, 'SCALE').…”